sleep

1. sleep Useful information about sleep for patients This Photo by Unknown Author is licensed under CC BY-SA

2. objectives • What is sleep? • How much sleep do we need? • what happens during sleep? • Benefits of sleep • Factors that adversely affect sleep • What is sleep deprivation, signs of sleep deprivation • Adverse effects of sleep deprivation • Sleep disorders – insomnia, sleep apnoea • Drugs causing sleep disturbances • Tips for getting good sleep • References

3. About sleep This Photo by Unknown Author is licensed under CC BY-SA Sleep or Nidra is something every human being cherishes. Those who can sleep effortlessly and adequately consider themselves blessed. For those who struggle with sleep, it is a major stress! According to a recent survey by fitness device firm GOQii (ET health, Jan 16, 2018), average sleeping hrs of Indian people have come down from 6.72 hrs per night from previous survey to 6.54 hrs in 2017 This module attempts to provide important information about sleep in simple manner

4. What is sleep? • The natural periodic suspension of consciousness during which the powers of the body are restored • Merrium Webster dictionary definition • A condition of body and mind which typically recurs for several hrs every night in which the nervous system is inactive, the eyes closed, the postural muscles relaxed and consciousness practically suspended • Oxford English dictionary definition This Photo by Unknown Author is licensed under CC BY-NC

5. Normal sleep • We spend third of our life sleeping, yet know very little about it • How much sleep do humans need per day? Depends on our age: • New-born babies: 14 – 17 hrs • Infants: 12 - 15 hrs • Toddlers: 11 – 14 hrs • Pre-schoolers: 10 – 13 hrs • School going: 9 – 11 hrs • Teenagers: 8 – 10 hrs • Young adults and adults: 7 – 9 hrs (at least 7 hrs of sleep is considered optimum for adults) • Older adults: 7 – 8 hrs (As recommended in 2015 National Sleep Foundation’s (USA) expert consensus review on duration of sleep)

6. What happens during sleep? • A good night’s sleep consists of 4 to 5 sleep cycles • Average time for each complete cycle at the beginning of sleep is 70 to 100 minutes, increases to 90-120 minutes subsequently • Each cycle has two distinct sleep stages – NREM (Non Rapid Eye Movement) and REM (Rapid Eye Movement)

7. What happens during sleep (cont.) • Cardiovascular system: • Throughout the night, heart rate and blood pressure continue to fall and rise. • In normal individuals, they do not pose any risk • In high risk individuals, risk of heart attack (myocardial infarction) may be greater in the morning, as there is sharp increase in heart rate and blood pressure during the awakening process • Respiratory system: • Breathing rate falls and rises during different stages of sleep, it is physiological • In susceptible individuals, may pose a risk of hypoventilation • Blood flow to brain: • During NREM sleep, decreased blood flow and metabolic activity in brain • During REM sleep, blood flow and metabolic activity in brain is comparable to wakefulness

8. What happens during sleep (cont.) • Kidney: • Decreased urine formation and flow • Endocrine (hormonal) system: • Growth hormone secretion increases that helps in growth and healing of cells and tissues • Increased secretion of melatonin – a sleep inducer in the body • Temperature: • Decrease in heat production, increase in heat loss, hence body temperature is lower during sleep

9. Benefits of sleep • Sleep makes us feel refreshed and rested every day even as our internal organs are working throughout the night • Sleep plays an important role in memory consolidation • Sleep helps one think clearly, improves learning skills, enables to focus better and reflexes are quicker • Sleep plays a critical role in immunity building (production of immature T cells, precursor of cells that provide our body with immunity, is highest during sleep) • Throughout the sleep, body releases hormones (e.g., growth hormone) that help in cell repair and control body’s use of energy This Photo by Unknown Author is licensed under CC BY-NC-ND

10. Factors that adversely affect sleep • Stress (# 1 cause cited for lack of sleep) • Modern life related issues adding to stress • Job related tensions, long commutes • Less/no personal time • Too much time in front of television, computers, cell phones etc. • Environmental noise pollution: Extremely high in India • Religious functions and processions • Weddings and other personal celebrations • Vehicular honking and other related noises • Poor sleep habits • Illnesses: chronic painful conditions, heartburn, conditions causing breathlessness etc • Drug side effects • Sleep disorder such as sleep apnoea This Photo by Unknown Author is licensed under CC BY-ND

11. Sleep deprivation and signs • Sleep deprivation is defined as less than 7 hrs of sleep a night • Signs of sleep deprivation: • Stress, mood swings, irritability, drowsiness during daytime • Feeling mentally exhausted, depressed • Groggy feeling, affecting concentration and memory • Waking up with sore throat, dry mouth or headache • Red puffy eyes, dark circles and bags under eyes • Craving for junk food, more coffee • Despite the threat it poses, sleep deprivation is not taken seriously by most people This Photo by Unknown Author is licensed under CC BY-NC

12. Adverse effects of chronic sleep deprivation • Lack of sleep over a period of time is associated with increased risk of several illnesses, such as, • Obesity • Diabetes mellitus • Cardiovascular illnesses – high blood pressure, heart attack, stroke • Cancer • Poor mental health • Alzheimer's disease (these patients also have difficulty in sleeping) • Poor immunity • Acne

13. Sleep disorders: Insomnia • Insomnia is defined as trouble either falling or staying asleep • Most people have occasional insomnia • Chronic (long term) insomnia is defined as lasting at least three nights per week for more than a month • Chronic insomnia can pose serious day time problems • Anxiety about falling asleep can make the matters worse • Elderly people often complain of insomnia (as many as 43% of elderly complain of insomnia) • Though ability to sleep becomes more difficult (may be partly linked to reduced melatonin formation with aging), the need for adequate sleep does not decrease with age This Photo by Unknown Author is licensed under CC BY-NC-ND

14. Sleep disorders: sleep Apnoea • It is serious sleep disorder when breathing is interrupted repeatedly during sleep, sometimes even hundreds of times! • During this time, brain and other organs in our body may not get enough oxygen supply • There are two types of sleep apnoea, however, the one due to obstruction to the air passage is most common – Obstructive Sleep Apnoea or OSA • What puts one at risk of sleep apnoea? • Age over 40, male sex, family history • Overweight/obese individuals, especially with large thick neck • Large tonsils, tongue with small jaw • Obstructions in the nose – deviated nasal septum, sinus issues, allergies • Gastro-esophageal reflux disease (where contents from stomach come back in the food pipe or oesophagus, causing heartburn)

15. Sleep apnoea: symptoms and long term consequences

16. Managing sleep apnoea • One should consult a specialist when sleep apnoea is suspected • Specialist doctor, among other things, may carry out special sleep apnoea test or polysomnogram to confirm the diagnosis • He may advise lifestyle changes (weight reduction, no alcohol, tobacco, sugar control in diabetics), give tips related to sleep positioning, or advise Continuous Positive Airway Therapy if needed This Photo by Unknown Author is licensed under CC BY-SA

17. Medications causing insomnia

18. Medications causing insomnia

19. Tips for good sleep: Occasional insomnia • As mentioned earlier, almost everyone has insomnia occasionally. • How to recover from poor sleep last night? • Try and stick to usual time to get up (i.e. try not to sleep 3 additional hrs because you were awake for 3 hrs at night) • Let the Sunlight come in the house, go out and exercise if feasible • Have coffee during the day (not too much) to stay alert • Eat light and early in the evening and go to bed at usual time • Can one make up for lost sleep? • To some extent, brief afternoon nap ( up to one hr) helps to make one feel fresh and rested. Too long a nap in the afternoon can interfere with sleep at night, leading to vicious cycle

20. Tips for good sleep: good sleep habits • Try to follow standard time and routine for bedtime and waking up including on weekends. • Have good physical activity schedule – exercises such as brisk walk for 30 minutes every day, however, avoid exercise close to bedtime • Switch off electronics – TV, mobile, computers at least 30 minutes before bed time, try reading a book, listening to soft music • Make the room dark and cool, use earplugs to block out loud external noise (e.g. religious processions) • Evening meal should not be too heavy, and eat at least 2 hrs before bedtime • Keep yourself hydrated throughout the day, but limit water after 09:00 pm, otherwise urge to pass urine will disturb sleep • If sleep is disturbed and you are unable to go back to sleep, it might be a good idea to sit for a while, read something till you feel drowsy again, than fretting in the bed and looking at the clock constantly

21. Foods that affect Sleep • Tryptophan is a substance found in many foods that has sleep promoting effects • Milk, milk products, honey, banana, nuts, eggs seeds are good source of tryptophan • Carbohydrate rich foods complement dairy products by increasing tryptophan levels • I have found that a cup of warm milk, with turmeric and honey at bedtime facilitates sleep • Fatty meals, fried foods, protein rich foods (e.g. meats) are harder to digest and can affect sleep – to be minimized at night time • Avoid caffeine containing medications at bedtime • Avoid alcohol (alcohol can make one sleepy initially, but later on disturbs the sleep, even causes nightmares)

22. Understand and tackle root cause

23. Sleeping pills? • There are several freely available in the Indian market • They can, however, make you feel groggy, less alert during day time, make you lose concentration and can lead to errors and accidents • They stop being effective after a while, so temptation to increase the dose, more side effects! • Addictive potential, so after a while one is not able to sleep without pills • They can have unpredictable, even life threatening actions in elderly • So avoid temptation to take one on you own as an easy option, do not listen to advice from family, colleagues, friends • Do not pressurize your doctor to prescribe one, he will do so if medically indicated! This Photo by Unknown Author is licensed under CC BY-NC

24. References: • Sleep disorders and sleep deprivation: an unmet public health problem. www.ncbi.nlm.nih.gov/books/NBK 19956/ (funded by National Institute of Health, USA) • NIH News in health, April 2013 • Armon B Neel Jr. Medications causing insomnia, AARP • Web MD and Medscape • Drugs.com • Merrium Webster and Oxford English Dictionary • Harvard Health Newsletters • On line picture library